Gaps in the Hepatitis C Continuum of Care among Sex Workers in Vancouver, British Columbia: Implications for Voluntary Hepatitis C Virus Testing, Treatment and Care

BACKGROUND: Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible. METHODS: Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers’ Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing. RESULTS: Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual/gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds. CONCLUSIONS: Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers

The cost of safe sex:Estimating the price premium for unprotected sex during the Avahan HIV prevention programme in India

There is some evidence that female sex workers (FSWs) receive greater earnings for providing unprotected sex. In 2003, the landscape of the fight against HIV/AIDS dramatically changed in India with the introduction of Avahan, the largest HIV prevention programme implemented globally. Using a unique, cross-sectional bio-behavioural dataset from 3591 FSWs located in the four Indian states where Avahan was implemented, we estimate the economic loss faced by FSWs who always use condoms. We estimate the causal effect of condom use on the price charged during the last paid sexual intercourse using the random targeting of Avahan as an instrumental variable. Results indicate that FSWs who always use condoms face an income loss of 65% (INR125, US$2.60) per sex act compared to peers providing unprotected sex, consistent with our expectations. The main finding confirms that clients have a preference for unprotected sex and that policies aiming at changing clients' preferences and at improving the bargaining power of FSWs are required to limit the spread of HIV

Interim modelling analysis to validate reported increases in condom use and assess HIV infections averted among female sex workers and clients in southern India following a targeted HIV prevention programme.

OBJECTIVES: This study assesses whether the observed declines in HIV prevalence since the beginning of the 'Avahan' India HIV/AIDS prevention initiative are consistent with self-reported increases in condom use by female sex workers (FSWs) in two districts of southern India, and provides estimates of the fraction of new infections averted among FSWs and clients due to increases in condom use in commercial sex after 2004. METHODS: A deterministic compartmental model of HIV/sexually transmitted infection (STI) transmission incorporating heterogeneous sexual behaviour was developed, parameterised and fitted using data from two districts in Karnataka, India. Three hypotheses of condom use among FSWs were tested: (H(0)), that condom use increased in line with reported FSW survey data prior to the Avahan initiative but remained constant afterwards; (H(1)) that condom use increased following the Avahan initiative, in accordance with survey data; (H(2)) that condom use increased according to estimates derived from condom distribution data. The proportion of fits to HIV/STI prevalence data was examined to determine which hypothesis was most consistent. RESULTS: For Mysore 0/36/82.7 fits were identified per million parameter sets explored under hypothesis H(0)/H(1)/H(2), respectively, while for Belgaum 9.7/8.3/0 fits were identified. The HIV epidemics in Belgaum and Mysore are both declining. In Mysore, increases in condom use during commercial sex between 2004 and 2009 may have averted 31.2% to 47.4% of new HIV infections in FSWs, while in Belgaum it may have averted 24.8% to 43.2%, if there was an increase in condom use. DISCUSSION: Increased condom use following the Avahan intervention is likely to have played a role in curbing the HIV epidemic in Mysore. In Belgaum, given the limitations in available data, this method cannot be used alone to decide if there has been an increase in condom use

Factors Associated with Sexual Violence against Men Who Have Sex with Men and Transgendered Individuals in Karnataka, India

There is a lack of information on sexual violence (SV) among men who have sex with men and transgendered individuals (MSM-T) in southern India. As SV has been associated with HIV vulnerability, this study examined health related behaviours and practices associated with SV among MSM-T.Data were from cross-sectional surveys from four districts in Karnataka, India.Multivariable logistic regression models were constructed to examine factors related to SV. Multivariable negative binomial regression models examined the association between physician visits and SV.A total of 543 MSM-T were included in the study. Prevalence of SV was 18% in the past year. HIV prevalence among those reporting SV was 20%, compared to 12% among those not reporting SV (p = .104). In multivariable models, and among sex workers, those reporting SV were more likely to report anal sex with 5+ casual sex partners in the past week (AOR: 4.1; 95%CI: 1.2-14.3, p = .029). Increased physician visits among those reporting SV was reported only for those involved in sex work (ARR: 1.7; 95%CI: 1.1-2.7, p = .012).These results demonstrate high levels of SV among MSM-T populations, highlighting the importance of integrating interventions to reduce violence as part of HIV prevention programs and health services

Assessment of the population-level eff ectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis

Background Avahan, the India AIDS initiative of the Bill & Melinda Gates Foundation, was a large-scale, targeted HIV prevention intervention. We aimed to assess its overall eff ectiveness by estimating the number and proportion of HIV infections averted across Avahan districts, following the causal pathway of the intervention. Methods We created a mathematical model of HIV transmission in high-risk groups and the general population using data from serial cross-sectional surveys (integrated behavioural and biological assessments, IBBAs) within a Bayesian framework, which we used to reproduce HIV prevalence trends in female sex workers and their clients, men who have sex with men, and the general population in 24 South Indian districts over the fi rst 4 years (2004–07 or 2005–08 dependent on the district) and the full 10 years (2004–13) of the Avahan programme. We tested whether these prevalence trends were more consistent with self-reported increases in consistent condom use after the implementation of Avahan or with a counterfactual (assuming consistent condom use increased at slower, pre-Avahan rates) using a Bayes factor, which gave a measure of the strength of evidence for the eff ectiveness estimates. Using regression analysis, we extrapolated the prevention eff ect in the districts covered by IBBAs to all 69 Avahan districts. Findings In 13 of 24 IBBA districts, modelling suggested medium to strong evidence for the large self-reported increase in consistent condom use since Avahan implementation. In the remaining 11 IBBA districts, the evidence was weaker, with consistent condom use generally already high before Avahan began. Roughly 32 700 HIV infections (95% credibility interval 17 900–61 600) were averted over the fi rst 4 years of the programme in the IBBA districts with moderate to strong evidence. Addition of the districts with weaker evidence increased this total to 62 800 (32 000–118 000) averted infections, and extrapolation suggested that 202 000 (98 300–407 000) infections were averted across all 69 Avahan districts in South India, increasing to 606 000 (290 000–1 193 000) over 10 years. Over the fi rst 4 years of the programme 42% of HIV infections were averted, and over 10 years 57% were averted. Interpretation This is the fi rst assessment of Avahan to account for the causal pathway of the intervention, that of changing risk behaviours in female sex workers and high-risk men who have sex with men to avert HIV infections in these groups and the general population. The fi ndings suggest that substantial preventive eff ects can be achieved by targeted behavioural HIV prevention initiatives

Differences between seven measures of self-reported numbers of clients of female sex workers in southern India: implications for individual- and population-level analysis.

Quantifying sexual activity of sub-populations with high-risk sexual behaviour is important in understanding HIV epidemiology. This study examined inconsistency of seven outcomes measuring self-reported clients per month (CPM) of female sex workers (FSWs) in southern India and implications for individual/population-level analysis. Multivariate negative binomial regression was used to compare key social/environmental factors associated with each outcome. A transmission dynamics model was used to assess the impact of differences between outcomes on population-level FSW/client HIV prevalence. Outcomes based on 'clients per last working day' produced lower estimates than those based on 'clients per typical day'. Although the outcomes were strongly correlated, their averages differed by approximately two-fold (range 39.0-79.1 CPM). The CPM measure chosen did not greatly influence standard epidemiological 'risk factor' analysis. Differences across outcomes influenced HIV prevalence predictions. Due to this uncertainty, we recommend basing population-based estimates on the range of outcomes, particularly when assessing the impact of interventions

The structure of sex work : variability in the numbers and types of sex partners of female sex workers in southern India

Background and objectives: There is limited knowledge of sexual structure (i.e., the numbers, types and distributions of sex partners and patterns of sexual contact) and its relationship with HIV infection and prevention among female sex workers (FSWs). The objectives of this study were therefore: to examine the social and environmental factors associated with the numbers of clients of FSWs; to characterize heterogeneity in sexual structure and assess how sexual structure influences HIV prevalence; and to examine the impact of an HIV intervention on condom use by different partners (clients, intimate partners), as reported by FSWs. Methods: This study used data collected from FSWs and clients in Karnataka state, southern India as part of the Avahan AIDS Initiative, an ongoing large-scale HIV intervention. Bivariate and multivariable statistical techniques were used to examine the relationships between two outcomes (numbers of clients and condom use) and key social and environmental factors, including exposure to the Avahan intervention. A deterministic compartmental mathematical model was developed to understand how sexual structure influenced HIV prevalence on a population level. Results: Sexual structure displayed substantial geographic variation across districts in Karnataka. The most common predictors of higher rates of clients were a reliance on sex work as sole income, younger age, and being single or cohabiting as compared to married. The effect of the solicitation environment (e.g., brothels, public places, homes) varied by district. Intervention exposure was associated with increased condom use by FSWs’ clients, but not their intimate partners. Mathematical modelling identified sexual structure parameters with the largest influence on increasing (numbers of clients of FSWs; numbers of visits to FSWs by clients; frequency of sex acts with repeat clients) and decreasing (duration of the repeat FSW-client partnership; fraction of repeat clients) HIV prevalence within and across districts. Conclusions: Differences in the sexual structure of FSWs and their commercial clients have important implications for HIV transmission dynamics. In light of findings related to both differences in sexual structure across districts and the impact of an intervention on condom use by different partners of FSWs, HIV prevention planners need to tailor interventions to respond to local contexts.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

An ethnography of the nuclear disarmament movement

This thesis is an ethnography of the contemporary nuclear disarmament movement. It describes some of the ways in which participants symbolize, articulate and act on their belief that human survival is seriously endangered by the existence and proliferation of nuclear weapons. Illustrations are given of the manner in which participants invoke the authority of scientific, military and technical "experts" to substantiate their claims of the imminence of catastrophe. Also depicted is the participants' practice of posing alternatives for humanity, the most basic formulations being: "disarmament or annihilation," and "transformation or catastrophe." They insist that humanity has an urgent choice to make: to achieve nuclear disarmament or face annihilation. They warn that a nuclear holocaust is inevitable unless steps are taken immediately to prevent it. Some participants believe that the steps necessary to avert catastrophe involve the complete transformation of the existing world order. In this thesis. I focus on those who believe that disarmament and human survival demand a complete transformation of the existing world order, and who have adopted a strategy based upon an ideology of "nonviolence" to accomplish this. Two events organized by participants are described which are part of an overall nonviolent strategy to achieve nuclear disarmament and a transformed world. A case study is made of the world view and approach to nuclear disarmament of a well known proponent of "nonviolence," who had a great deal of input in the planning and organizing of one of these events. My concerns and interests as a new participant in the disarmament movement in Vancouver, and more especially in the Trident campaign, have to a large degree informed which facets of the nuclear disarmament movement are described in this thesis. The Trident campaign is an on-going series of protest activities organized with the goal of halting the deployment of the Trident submarine nuclear weapons system, and the construction of the Trident base at Bangor, Washington. I begin the introductory chapter by providing an autobiographical sketch which is intended to "set the scene" for the following ethnographic description of certain aspects of the nuclear disarmament movement. A brief summary of each of the chapters is provided, followed by a discussion of methodology. This discussion considers: my purposes in choosing this topic; my role as both researcher of, and new participant in, the movement; data collection procedures; and some of the cognitive and ethical difficulties which arose in producing this ethnography. The data collection activities which are the basis for this ethnographic description of the movement are: fieldwork; taped in-depth interviews; and the collection and examination of various kinds of written and audio-visual materials produced primarily by movement participants in Canada and the United States. Fieldwork experience was mostly with Canadian and American participants in the Trident campaign. The second chapter, entitled "Millennial Dreams and Apocalyptic Nightmares," draws attention to a few of the symbolic themes evident in participants' call for a new and better social order, and their warning of imminent catastrophe. I observe that frequently participants draw upon Judaeo-Christian images, symbols, themes and values embedded in the Western cultural tradition to express their longing for a new world of universal peace, justice and prosperity, and also to express their terror of the cataclysmic destruction of human civilization. The third chapter, entitled "Mobilizing for Survival," describes two events or "demonstrations" which took place at the time of the first United Nations Special Session on Disarmament in May 1978. The first was held in the vicinity of the Trident base. The climax of this demonstration was a carefully staged trespass action onto the naval facility which resulted in the arrest of 265 people. Participants referred to their illegal entry of the base as an "action of civil disobedience." The second demonstration took place in New York City near the site of the United Nations buildings. Both events are viewed as attempts to symbolize, proclaim, and somehow bring into being a new world: a world without war. The fourth chapter, entitled "The Choice: Kingdom or Holocaust," is a case study which examines the world view and approach to nuclear disarmament of which Jim Douglass is a well known proponent. Douglass has had considerable input in the group process of planning and organizing the Trident campaign. His most recent book, Lightning East to West, outlines his vision of the spirit and strategy of this campaign. Greatly influenced by the Trappist monk and writer, Thomas Merton, Douglass' approach to nuclear disarmament incorporates elements of Christianity along with Gandhian principles of nonviolence. In the concluding chapter I briefly review some of the main themes depicted in the ethnography, and finish with some personal reflections. The appendix provides the trial statements of three, persons who committed civil disobedience at the Trident base in Bangor, Washington.Arts, Faculty ofSociology, Department ofGraduat